Dealing with drug abuse

Drug addiction is a growing problem in India and drug abusers can recover if they are motivated to seek treatment.

Rahul was 30 when he died of a drug overdose, alone in a hotel room. He had been abusing drugs for 10 years, since he was in college. He began with smoking marijuana with friends, but after a tragic motorcycle accident when his pillion rider was killed and he was badly injured, he began to abuse painkillers. He graduated to multiple mainline drugs and became dependent on them. Despite several rehabilitation efforts, he was unable to give up the habit. After his parents asked him to leave the house, he went to stay with his sister's family, but even her support and motivation did not help him quit the habit. He wanted desperately to live a normal life, but he simply lost hope.

HOPE, support and motivation are what thousands of people like Rahul, who die in their prime every year in India owing to drug abuse, need in plenty. The number of drug abusers may be high, but help is available, for those who seek it.

Identified as a disease in 1956 by the World Health Organisation and the American Psychiatric Association, drug abuse is the illicit consumption of any naturally occurring or pharmaceutical substance for the purpose of changing the way in which a person feels, thinks or behaves, without understanding or taking into consideration the damaging physical and mental side-effects that are caused.

Drug abuse and addiction lead to a complex set of social, medical and economic problems with serious implications. According to experts, it is widely prevalent, cutting across age, class and gender. Yet, it is difficult to estimate the number of drug abusers or formulate a comprehensive approach to deal with the issue primarily because it involves a "hidden population" that does not seek treatment and hence remains under-reported. This makes it difficult to assess the problem, estimate costs, both social and economic, and design intervention strategies.

Realising the need for extensive data and information on the issue, the Ministry of Social Justice and Empowerment and the United Nations Office on Drugs and Crime published in 2004 one of the most comprehensive baseline studies, "The Extent, Pattern and Trends of Drug Abuse in India: National Survey". The major components of the survey that used multiple methodologies and indicators included a National Household Survey (NHS) of randomly selected men across the country; the Drug Abuse Monitoring System (DAMS), which compiled data from new patients at treatment centres; a Rapid Assessment Survey (RAS), which analysed information from interviews with drug users, key informants and focus group discussions in 14 urban sites across the country; and several thematic studies on women, the rural population, people in the border areas, and prisoners.

According to the report, apart from alcohol (62.46 million users), cannabis (8.75 million users), opiates such as heroin, opium, buprenorphine and propoxyphene (2.04 million users), and sedatives (0.29 million users) are the drugs most abused. Between 17 per cent and 20 per cent of current drug users were classified as dependent users (addicts). The users were mostly male; the Rapid Assessment Survey found only 8 per cent of drug users to be women. By and large, young, under-employed males and marginalised populations were prone to drug abuse. Drug abuse causes a range of health complications - from weakness, loss of body weight and respiratory disorders. Often, under the influence of drugs, addicts also indulge in high-risk behaviours such as unsafe sex and needle sharing, which has contributed to the spread of infectious diseases such as HIV/AIDS and Hepatitis C. One of the most important effects of drug abuse is impaired judgment and a lack of rational thinking. Addicts develop psychological problems such as depression, anxiety and irritability, apart from personality problems.

People start on drugs for a number of reasons, from curiosity and recreation to the need to cope with stress. What begins as abuse can often lead to dependence. Physically, the body develops tolerance for it, and more of the drug is needed to experience the same effect. This leads to increases in consumption, which eventually leads to physical dependence. At that stage, lack of the drug causes severe withdrawal symptoms, which disappear if the drug is taken again; this ensures that abusers remain hooked (see chart).

Users are almost always young, initiated into drug use with alcohol and then with cannabis and its derivatives. Often, they graduate to other, more potent, drugs such as narcotic analgesics, stimulants, depressants, hallucinogens and volatile solvents. Most abusers consume multiple drugs. According to Dr. S. Mohan Raj, a psychiatrist in Chennai who has been treating patients with drug dependence problems for several years, the easy availability of drugs, curiosity, peer approval and thrill-seeking are the most common reasons for drug abuse among the youth.

Partha (26), a regular party-goer in Chennai, says that it is easy to get marijuana and heroin in the city, but more expensive "party" drugs such as acid, ecstasy and cocaine are usually ordered from dealers in Goa, Manali, Mumbai and Bangalore.

The incidence of drug abuse is also high among people with untreated psychiatric or emotional problems, who often resort to taking drugs as a coping mechanism. Thus drug abuse may be primary or secondary to an existing emotional problem. Deeper emotional issues caused by dysfunctional families, feelings of self-hate, low self-esteem, and physical or mental abuse are some issues that need to be addressed during the identification and treatment of the problem.

AS in all diseases, timely treatment is essential. But unfortunately warning signs often go unheeded, especially among the youth. There is almost always deterioration in the normal daily functioning. Sleeping late, mood changes, deterioration in academic performance, behaviour problems such as aggression, rebelliousness and hyperactivity, lack of concentration and so on, are often ignored by family members as signs of adolescence rather than symptoms of addiction. To sustain their habit, with which they become obsessively preoccupied, addicts often lie, steal and manipulate family members.

According to Dr. R.R. Cherian, Director, Research and Treatment Programmes, of the Chennai-based T.T. Ranganathan Clinical Research Foundation, often the drug abusers do not have a chance to develop a personality and values of their own because they start on drugs very young. Some are college dropouts, and most have no commitment to work, marriage or family.

A patient's recovery process thus involves not only abstinence but also lifestyle changes. Detoxification, the first phase in treatment, involves medical management to make the withdrawal process safe and comfortable. For effective care and full recovery, psychological support is necessary and coexisting psychiatric problems have to be identified and treated simultaneously with the addiction. According to Dr. Cherian, bringing the abusers back into the mainstream as soon as possible is important for complete recovery. It is also crucial not to make an issue of past failures. Motivating abusers to seek treatment and abstain from drugs is another key factor, and the role of family, friends and employers is crucial in this. Says Dr. Mohan Raj: "If a person says, `I want to give it up but I am not able to', then it is easy for us to do whatever is needed to be done. But if he is not keen on stopping, whatever we do is not going to be successful."

In fact, according to the various components of the National Survey, hardly a third of drug-dependants reported having taken treatment (it was as low as 2 per cent in one of the components). There was also a significant time lag between the onset of dependence and the seeking of treatment, largely owing to a lack of knowledge about the need for treatment and rehabilitation and access to treatment facilities.

There is a general perception that "will power" alone is enough to stop taking drugs. While personal motivation is indeed crucial to recovery, it is important that patients and their families know that drug abuse is a disease that can be treated with appropriate and timely medical and psychological help.

Often, people seek treatment only after reaching a dependent stage. Close family members are often reluctant to seek professional help because they lack knowledge about drug abuse, do not want to accept the extent of the problem, or fear social ostracism. Dr. Cherian says: "We have to educate the family, educate them about relapses... the family is always in denial... Sometimes we tell them to be tough with the patient, but they are not willing... they do not know how to be ... Also, addicts need to be made accountable for their own lives... "

Family counselling is important particularly as dealing with an addict can be physically and emotionally draining and it usually focuses on educating the family about the issues involved and how to deal with the situation without getting angry, judgmental or frustrated. For instance, it is natural for family members to doubt what the recovering addict says. But they need to understand that this can damage his self-esteem and lead to a relapse.

Relapse prevention is also an important part of the recovery process. Isolating recovering addicts from friends who use drugs is essential. Support groups such as Narcotics Anonymous (N.A.) (an international brotherhood where recovering addicts help and motivate each other to abstain from drug abuse) are of enormous help in preventing a relapse.

Abdul, a member of N.A. in Chennai, says that he has been in and out of rehabilitation programmes 20 times, but it was only after he joined N.A. that he was finally able to give up drugs.

GIVEN that drug addicts come from all walks of society, interventions need to be localised. Apart from government strategies for the reduction of demand and supply of drugs , prevention interventions targeted at specific subgroups are also needed.

According to the National Survey, focussed interventions are needed to prevent the initiation of new users and the progression of occasional and casual users to dependent users, and for the treatment, aftercare and rehabilitation of established dependent users. The survey also found that prevention programmes based only on information dissemination were rarely successful, especially if the approach depicted exaggerated risks associated with drug use in order to frighten people into abstinence. According to the survey, a less sensational, scientific approach, which presents accurate information of facts and risks, would be highly effective.

FOR instance, the issue of drug abuse is rarely addressed in schools. It is important that parents and educational establishments carry out targeted interventions as most users get initiated into drugs in the high school or college stage.

Another vulnerable group is the rapidly growing middle class with rising purchasing power. Drug abuse is rising in this population. While there is a huge change in the lifestyles of people in this group there is no corresponding rise in social nets to protect them.

In Chennai, Partha feels that the social circle has grown because of the increasing presence of Business Process Outsourcing outfits and Information Technology companies that employ young people in large numbers. There are very few places where these people can go for entertainment or to socialise. Clubs and lounge bars are expensive and are also required now to shut early. (The city police cracked down on bars and pubs after an incident in which a young girl died after being run over allegedly by four drunken youth.) As a result, many people have nowhere to go after midnight and tend to get together at friends' homes and "smoke grass" or "do a few lines of cocaine", he says, adding, "Canabis is simply the cheapest way to `get a trip'. Alcohol is expensive."

At the lower end of the spectrum of those vulnerable are a rising number of educated unemployed graduates. Rural people, another vulnerable group, are dominant opium abusers. According to the National Survey, between 51 per cent and 76 per cent of drug users were from rural areas, and between 16 and 49 per cent were illiterate.

IT is a matter of concern that more and more women are becoming drug-dependent, and it is essential that a gender-specific approach is taken to address the issue. According to the National Survey, interventions among women have to examine issues such as drug abuse by women themselves, the burden on women due to drug abuse in the family, treatment, and access to treatment available to them.

Data from the thematic study on drug abuse and women carried out as part of the National Survey show that 30 out of 75 women drug abusers were "Injecting Drug Users", which belies the myth that most women abuse only tranquillisers. Another study of the Survey reported that the burden on women due to drug abuse by a family member was significant, affecting their health apart from isolating them and their family from friends and society. Drug-related domestic violence was also quite common. The study also showed that women drug abusers often felt the lack of adequate treatment facilities and the need for separate treatment centres.

Given the large and rising number of drug abusers and the complex nature of the problem, it is important that the issue is brought into the domain of public health care and related to such other issues as crime prevention, health care, lifestyle changes and education. It should become part of a larger public discourse, rather than a problem to be dealt with after it reaches a chronic stage.

(The names of persons affected by drug abuse have been changed in the article.)